Evaluation on Hope and Psychological Symptoms in Infertile Couples Undergoing Assisted Reproduction Treatment

Background: This study evaluated hope, depression, anxiety, and stress among three groups of infertile couples. Materials and Methods: This cross-sectional study consisted of three groups of infertile couples-candidates for oocyte donation (n=60), embryo donation (n=60), and normal infertile (n=60). Participants included couples seen at Royan Institute, Tehran, Iran between 2013-2014 who were at least 18 years of age and could read and write in Persian. Participants provided demographic and general characteristics and completed the Persian version of the Adult Trait Hope Scale (hope, agency and pathway) and Depression, Anxiety, and Stress Scale (DASS). Data was analyzed by the paired t test, ANOVA, ANCOVA and Pearson correlation tests using SPSS statistical software. Results: Overall, 180 infertile couples participated in the three groups. There was a significant higher mean score for hope in husbands compared to wives in the normal infertile group (P=0.046). Husbands in the normal infertile group also had a significantly higher mean score for pathway (P=0.032). The frequency of anxiety significantly differed in female subjects (P=0.028). In the normal infertile group, the anxiety distribution significantly differed between wives and husbands (P=0.006). There was a significantly different stress frequency in male subjects (P=0.048). In the embryo donation group, stress significantly differed between wives and husbands (P=0.002). In the normal infertile group, stress also significantly differed between wives and husbands (P=0.05). Conclusion: The results have suggested that hope might be important in reducing psychological symptoms and psychological adjustment in those exposed to infertility problems who follow medical recommendations, which accelerates recovery. It is recommended to hold psychological counseling sessions (hope therapy) during reproduction cycles.


Introduction
Infertility is an unpleasant, unexpected experience for individuals. According to a populationbased study in Iran, the overall prevalence of lifetime primary infertility among couples is 17.3% (1). Infertility is associated with tremendous negative psychological and mental burdens on both infertile men and women, in addition to somatic and sexual disorders (2). The typical, common psychological problems that result from infertility are anxiety, and lower marital and sexual satisfaction (3, 4). When infertility treatment takes a long time or in the event of treatment failure, infertile patients are more likely to encounter hopelessness. The loss of hope to have a child is important because hope is one of the main psychological needs (5). In other nal positive feelings toward solving an existing (6) as "a reciprocally derived sense of successful agency (goal-directed determination) and pathways (planning of ways to meet goals)". What can be deduced is that agency is the perception that one can reach his/her goals, whereas pathways is known as to reach these goals should the need arise (7). It is expected that people with high levels of hope can think about pathways to reach their goals, deal with diseases better, and generate additional coping strategies (8) so that fear, anxiety, and fatigue occur less order to facilitate the treatment process during a life crisis, because this is considered an important part To the best of our knowledge, no studies have examined the utility of Snyder's theory of hope in patients who suffer from infertility. This study aimed to investigate the levels of hope as conceptualized by Snyder in infertile couples who undergo -tively or negatively related to major psychological symptoms commonly experienced by infertile patients (i.e., anxiety, stress, and depression).

Materials and Methods
We conducted this cross-sectional study on infertile couples who referred to Royan Institute, a referral infertility clinic in Tehran, Iran between The study sample consisted of three groups of infertile couples-candidates for inclusion criteria were aged 18 years or older, a history of infertility, and ability to read and write in Persian.
The Ethical Committee of Royan Institute ap-dentiality of the data were clearly explained for all participants. We reassured all eligible individuals that acceptance or refusal to participate in the re-dures. Voluntary completion of the questionnaire was considered as written informed consent. Participants completed three questionnaires. First, the demographic questionnaire included age (years), sex (male or female), educational levels (under diploma, diploma and academic), duration of mar-riage (years), and duration of treatment (months). Second, participants completed the Adult Trait Hope Scale published in 1991 by Snyder et al. (11). This 12 item self-report instrument contains two subscales: agency and pathway. These components include a sense of personal agency related to goal attainment (4 items) and the ability to recognize/ generate pathways to reach a goal (4 items). This questionnaire also includes 4 items which do not belong to either of the above dimensions. The items are answered by an 8-option Likert scale. Each subscale has a score that ranges from 4 to 32. Hope is scored from 8 to 64, so that higher scores indicate a higher level of agency, pathway, and hope, respectively. We have used the Persian version of hope The relationship between individual independent variables (demographic, and duration of treatment and marriage) and dependent variables (hope, agency, pathway, anxiety, depression, and stress) cient and we conducted the paired t test (between wives and husbands), ANOVA (between groups of infertile in hope subscales), and chi-square test (between groups of infertile in depression, anxiety and stress). Moreover, the mutual effects of demo-graphic characteristics, hope, and groups studied -

Results
academic educations. The mean duration of marmonths. The demographic and fertility characteristics of the participants are given in Table 1. higher mean score for hope compared to wives in male and female patients between groups. There for agency between wives and husbands in each cantly differ in male and female patients between groups. In the normal infertile group, the husbands served in the mean score for pathway in male and female patients between groups.   Table 3, the distribution of depression (normal, slight, medium, severe, and of anxiety (normal, slight, medium, severe, and --frequency of stress (normal, slight, medium, se- Additionally, bivariate correlations were conducted among the subscales of the DASS and Adult Trait Hope Scale. Agency negatively and Results of the ANCOVA test showed that regardless of demographic variables, the mean differences in hope (Table 5).

As shown in
Discussion study that measured two components of the Adult Trait Hope Scale, agency and pathway, in Iranian infertile patients undergoing assisted reproduction treatment according to Snyder's theory. This jects into three groups, oocyte donation, embryo donation, and normal infertile, because the main hypothesis was that a difference existed in hope subscales among these groups and between wives and husbands. Mainly, we hypothesized that those who undergo donation (either embryo or oocyte) could show different hope and other psychological properties compared to other infertile participants. However, many studies have investigated hope in the context of chronic diseases, such as cancer (7, 8). The results of these studies have revealed that hope physiologically and emotionally helped patients tolerate the crisis of the disease (18, 19). Hope is considered an essential element in a chronically ill patients' life and has a high impact on their adaptation to the disease. Patients who have high levels of hope alleviate psychological tensions better through application of more efproblem solving, which affect various stages of the disease process (16,18,19). For many infertile patients, the effect of infertility and notably of medical therapy is a considerable emotional stress. It has been shown that infertile women undergo more tension, anxiety, depression, self-reproach, vealed that hope was one of the main effective factors for successful IVF (21).
bands had more hope than wives in the normal infertile group. Further investigation into the two components of hope indicated in the normal inpathway in husbands. The results of this investiga-ies that showed strong inverse relations between hope and psychological symptoms in patients who suffer from chronic diseases. Berendes et al. found  Increasing levels of hope resulted in anxiety reduction (24). Some researchers also reported that hope was accompanied by reductions in depression symptoms (8, 25). Studies on the effect of psychological and consultative interventions on the psychological disorders and pregnancy outcomes in infertile couples have shown that psychological therapy effectively reduced anxiety and depression, and increased pregnancy rates (16). A positive psychological treatments, hope therapy, can enhance infertile women's general health and subsequently improve family health. Therefore, hope therapy is recommended for infertile individuals to be offered with assisted reproductive techniques in order to enhance the quality of life and help these individuals cope with their problems (9, 16). Our study had several limitations. First, an inherent limitation of this study might be its generalizability. We relied on patients who presented to only one center, a referral clinic for infertility treatment in Iran where patients throughout the country come to this center. Second, the cross-sectional nature of the study only allowed for correlations, but not conclusions on causality.
Conclusion der's construct of hope in a sample of infertile couples. The results suggest that hope may be important in reducing psychological symptoms and psychological adjustment in those with infertility problems who follow medical recommendations which would accelerate recovery. We suggest that psychological counseling sessions (hope therapy) be offered during reproduction cycles. 25. -